A pilot study to develop a tool for the assessment of students' clinical record keeping

Abstract

Background The ability to develop and maintain contemporaneous and accurate clinical records is a medicolegal requirement. It follows therefore that preregistration health students' skills to write such ought to be assessed. Objective The aim of the present study is to develop an audit tool to evaluate student clinical record keeping in university on-campus clinics. Methods The project reported on here included a literature review to identify current practice in measuring accuracy in record keeping and to identify a suitable audit tool for educational purposes. We then adapted the tool to more closely align with Australian Health Practitioner Regulatory Agency requirements. We trialled the u..